As international HIV funding declines, nations are bracing for a future with less money and tougher choices. In countries like donor-dependent Malawi, a new UNAIDS tool is already beginning to shape how to rationalize their HIV responses to cope with the altered circumstances.
Malawi seems to have read the writing on the wall and is in the early phases of costing its HIV programming to see what it will take to make the national response sustainable.
It is also receiving UN agency support to evaluate national HIV program in light of the investment framework recently released by UNAIDS, which is guiding the choices as national programs bend to the pressures to rationalize expenditure.
The framework, published in a June 2011 edition of The Lancet medical journal, advocates that countries spend money on a basic set of six activities in HIV care and treatment, including prevention of mother-to-child transmission, medical male circumcision, and increasing access to antiretroviral (ARV) treatment.
Modeling suggests that, if implemented, the framework could avert about 12 million new HIV infections and almost 8 million AIDS-related deaths by 2020.
Dr. Mary Shawa, Principle Secretary for HIV/AIDS in the Office of the Presidency, said Malawi will look to non-traditional donors like China to shore up HIV programming, and may also explore innovative financing measures. However, the UNAIDS Country Coordinator in Malawi, Patrick Brenny, says there's no denying the impact that reduced funding will have on HIV programs.
"More countries are going through these formal exercises because the fat days are over, the funds aren't enough to go around or go as far," Brenny told IRIN/PlusNews. "In the past, when there was a lot of money to go around, you could afford to do all kinds of things. As resources become scarcer, we have to ask, 'What are the smartest investments?'"
With an 11 percent HIV prevalence rate, Malawi has already made painful choices in its programming. The country still relies heavily on the Global Fund, which provides as much as much as 70 percent of the HIV and TB response. Yet UNAIDS notes that in 2011 the government is funding only 1 percent of the HIV/AIDS response.
According to international humanitarian medical agency Médecins Sans Frontières (MSF), Malawi's Round 10 funding application to the Global Fund was denied largely because it was deemed too ambitious. The country had to forgo increasing HIV viral load monitoring, improving early infant HIV diagnosis, and scaling up medical male circumcision, MSF said in a recent statement.
The alleged refusal of funders to finance overly ambitious proposals may be a sign of the pressure being put on countries to rationalize HIV and development funding, against the backdrop of the global economic downturn, as Brenny pointed out.
This may also be embodied in what UNAIDS describes as a shift away from "needs-based" programming.
"Countries are also feeling the pinch of the global economic meltdown, and are pulling back and tightening their belts, and look at new areas for more investments - HIV is no exception," said Henry Damisoni of UNAIDS in Johannesburg, South Africa.
"Over the years, a lot of money [has been invested] but if we can't demonstrate meaningful results out of those investments, there is no justification for us to ask for more money," he said.
"Demonstrating a need for a particular program is no longer sufficient. We're going to have to generate concrete evidence to demonstrate the sustainable gains we're going to make [from the money]."
In Malawi, where 305,000 HIV patients are on ARVs, investment will likely focus on prevention, said Robert Ngaiyaye, executive director of the Malawi Interfaith AIDS Association, who also sits on the national body responsible for coordinating Global Fund grants, known as the country coordinating mechanism.
About 70,000 Malawians are newly infected with HIV every year, according to UNAIDS.
"That's a huge future mortgage of people who will need treatment... for the rest of their lives," Brenny noted. "How do we ensure that... [the number of new infections] becomes less? Because if we're not doing that, then we are mortgaging the future."
Malawi may have difficulty in adopting the investment framework's focus on most-at-risk populations because same-sex relationships are still criminalized.
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